What would you do?

[WJ700]

I'll go with what my gut instinct is telling me in any case. However, at some point you have to trust the people in your team and part of that team is Medlink. Again,it would have to be a very compelling argument for me to go against what Medlink says. I'm not saying I wouldn't ever. We use our past experiences every day, and if its causing a bias... its probably because I have learned something.

[Rockie]

Fair enough. I don't think there is an absolute right way or wrong way on this one, just what makes you feel comfortable.

[shankdown]

I see I'm coming in late on this one, I know, but it seems to me that following MedLink would be the wise choice regardless of the opinion of the doctor almost 99.9% of the time. (I find it amusing, by the way, that there's ALWAYS a doctor on board).

It was stated there that there are all kinds of doctors, and a medical doctor with credentials is pretty much the only one you can really trust. And frankly, I don't even know what a doctor's credentials would look like. Presumeably they'd be rather easy to forge. So in this day & age, the sick passenger & the doctor with 'credentials', could easily be a tag-team to get the airplane to land somewhere short of the intended destination; a hijack, of sorts, without appearing like one. (I've actually heard a post 9/11 story about this very situation, where a nurse, who was assisting a 'sick' passenger in the front galley, was desparately trying to convince the crew that they needed supplies out of the medical kit held in the cockpit, and were actively trying to get in there. MedLink told them that there was no reason they'd need to access it, and to keep the door closed and continue to destination. Upon further investigation, the random nurse who happened to be on board - and, coincidentally, also spoke farsi, the language of the passenger - booked her ticket from the same ip address as the 'sick' passenger who was seated nowhere near her.) And beyond that, there are many hypochondriacs out there, who always think they're dying. And those people tend to become more so when they're afraid of flying. So, you can't really land because someone with a cough think's they've got the bubonic plague, or someone with heartburn thinks they're having a heart attack.

So, there's always a possibility that MedLink could be wrong, but they've got the professional training to make those calls. We may as well listen to them, as that's why they're being paid the cash they're getting paid. And besides, if I was a passenger on a flight, and the Captain decided to land because the person beside me was hyperventilating, just so he could cover his ass, I'd be pissed off severely. And if I was the Captain, and someone died as a result of a wrong decision by MedLink, I'd be disappointed, but I would still be able to sleep at night.

Anyways, them's my thoughts. Good thread, though.

Shankdizzle

[square]

aw shoot I dont know

[Biff]

I think having MedLink on board makes the answer obvious. They tell you to do something, you would be negligent not to do it. If the supposed expert on board is adamant, the phone should go to him to converse directly to the Medlink doctor(if it's allowed under the SOP's). If he can convince Medlink, then you do what Medlink says, if he can't convince Medlink, then you do what Medlink says. They are the experts, the guys up front are not, the doctor in the back might be or might not be.

[venc]

I'll throw another curve into this. Even if the MD in the back says to land he may not be trained in emergency care (i.e. a GP). On a side note I was told a story from a cop that brought in a family doctor to certify the death of his patient (the coroner was too busy that day and this is sometimes done). There was yellow 'stuff' coming out of the nose of the dead guy. The doctor was concerned with that until the cop told him that he had been to a few of these types of deaths and this was normal. The point is that while he may have a medical degree, he may not have the experience/training to deal with this type of situation. This doctor spent all his time in his office where the patient walks in and out again and hadn't seen a recent death.

Personally, I MIGHT take the opinion of a paramedic over that of a family doctor due to the nature of his experience and training.

Morale of the story, even if the person is a certified medical doctor, try to get a handle of his type of medical training and experience before you use his advice to trump medilink/statMD.

venc

[Rockie]

OK, say you are feeling really really poor and your wife takes you to your family doctor. He says get to a hospital right away because even though he might not be a specialist, he sees you are in obvious distress and need more medical care than he can provide. Your wife insists on calling Medlink on the phone to describe your symptoms to them and see what they say. Medlink doesn't think it's a problem. Would you go to the hospital?

I personally couldn't sleep at night knowing I went against a certified onscene medical doctor's advice and continued on to destination causing the death of a passenger when I could easily have landed...regardless of what Medlink said. Pissing off this person's seatmate for delaying his arrival is the least of my concerns. Years ago while flying as a passenger on a flight from Miami to Toronto we had to return to Miami because of a medical situation. Once on the ground an even further delay was caused by duty time exceedences with the cabin crew. I did not hear a single complaint from anyone around me because it would take a particularly self-centred a**h*le to put their convenience before someones else's very life.

[Biff]

Morale of the story, even if the person is a certified medical doctor, try to get a handle of his type of medical training and experience before you use his advice to trump medilink/statMD.

I don't get it. If you have a system like Medlink why are you trying to second guess it. Sure if you can't get a hold of them, you have to make a call, and obviously a doctor or medical person in the back is of great assistance and surely you would take the most conservative route. But if you can get in contact with them, they are there to tell you what to do. They have as much information as you and you as a pilot are trying to outguess them??? I don't get it. I don't get it. I don't get it.

You say to "try to get a handle of his type of medical training and experience before you use his advice to trump medilink/statMD" Again, I must be slow but I don't get it. How are you going to do that. Most pilots aren't trained in the medical profession, how are we going to determine firstly what his claimed qualifications are and what they mean and secondly how are we going to determine the veracity of his claims?

Medlink takes the liability and the responsibility for their decisions, they have the knowledge and the information. In my mind you are doing a disservice to your company, the passengers and your own financial health by not following their direction.

[Rockie]

Medlink takes the liability and the responsibility for their decisions, they have the knowledge and the information. In my mind you are doing a disservice to your company, the passengers and your own financial health by not following their direction.

"pilot-in-command" means, in relation to an aircraft, the pilot having responsibility and authority for the operation and safety of the aircraft during flight time;

By "aircraft" they mean by extension everyone on board it as well.

This is quoted from the Aeronautics Act, and I only include it to remind people that you as Captain are always solely responsible for the safety of the passengers, crew and aircraft. Everyone else advises you...but any and all decisions are your responsibility. You cannot delegate that responsibility or authority to Medlink or anyone else. It is your responsibility to make the most prudent decisions regarding the safety of everyone on board using the best information you have available.

For me that means if I have one fully qualified doctor on board and one on the phone, and either one of them says land...we land.

[Biff]

ARRRGGGHHH

I still don't get why you would argue with someone your company has hired to assess and then take responsibility for their decisions. Once again Medlink has being hired to assess and take responsibility for the health of your passengers. How in the world are you going to assess the qualifications of a self described medical expert on board. If they are so sure, let them talk directly to medlink and then follow what medlink says.

Sure you are the person responsible for the safe operation of the flight, that doesn't mean you disregard the professional opinion of someone much more qualified to make the decision than you. Part of being a captain is knowing when to listen to someone more qualified in an area than you are and then act on their advice. So unless you are a medically trained and competent medical provider, I would suggest that you follow the advice of the people that your company wants you to follow not some joe blow in the back of the aircraft. The other point that I should make is that Medlink also knows the physiological effects of flying on the body, which I would hazard to guess even alot of trained medical professionals are not up to speed on.

[Rockie]

Who's arguing? Perhaps I should have stated what I consider obvious. You don't believe anyone is a medical doctor until they produce documented proof of their licence to practice medicine. That makes them vastly more qualified than me to make a determination on a patient's health needs. And when one (any one, pick one) tells me the passenger needs to get to a hospital I listen to them like a good Captain and heed their advice. As for physiological effects of flying, none of them are beneficial. And being stuck in an aluminum tube at 8000 ft cabin altitude when you should be in a hospital is never good for you.

[Biff]

I guess my point was that sometimes medical folk will overreact due to being in an airplane at a higher altitude. MedLink doctors are up on the physiological effects of flying and will probably tend to not overreact.

[Rockie]

You're balancing that rather nebulous eventuality against a certified medical doctor physically examining a patient and correctly determining they require urgent medical attention. I will take more conservative onscene medical advice over less conservative third party remote diagnosis every day of the week, and it matters not one whit to me whether the company pays Medlink to assume that liability or not. They aren't responsible...I am.

[Biff]

Right on, good for you.

In my case I'm going to let the known experts make the call and take the responsibility.

If you choose to follow the other path, I would suggest you are responsible, legally, for everything that happens after that point. Hopefully your good judgement works and nothing untoward happens.

[Rockie]

Well I have two questions for you. Do you not consider a fully licenced medical doctor who has examined the patient an expert? And if I take the conservative approach no matter who recommends it (medlink or onboard doctor), what legal trouble could I possibly be in?

[Biff]

Do you not consider a fully licenced medical doctor who has examined the patient an expert?

This would be a difficult question for me as a pilot to make. Sure we can get him to pass his license up to the flight deck, now to figure it out!! Imagine giving a doctor(not an aviation doctor) our license and getting him to tell us what we are qualified to do. Next, is he current? My uncle is a radiologist and his license probably looks pretty impressive, does it mean he can make a diagnosis on a patient?? Probably not so much.

if I take the conservative approach no matter who recommends it (medlink or onboard doctor), what legal trouble could I possibly be in?

One example out of many. The "expert" on board says land immediately. Medlink says continue on to your destination(1 hour further down the line). You cordinate with ATC, (following the "experts" advise, disregarding Medlink) and they give you vectors to land at the nearest airport. It's the middle of the night, the tower is open and it is a rather large airport by a large city so all should be good. Unfortunately you get on the ground, no gates are open, they all have prepositioned airplanes on them for the next morning. You end up waiting two hours for the mess you created to be sorted out, meanwhile the passenger has expired. Now the obvious question if you were put on the stand, "Does your company have Medlink, did you talk to them and if so why did you not follow their advice?" Then the second question, "Is it not Company SOP to follow Medlink's advice?"

My point being, if you choose to follow someones else's recommendation other than the one approved by your company, be prepared to suffer the consequences. It's like any SOP, you can deviate from it(as in we are all capable of it) but if you do, you open yourself up to all sorts of recrimination if something happens. So my question would be, why not follow the SOP, accept that Medlink is the final medical authority on board and let them assume the final responsibility?

[Rockie]

A licenced MD is a licenced MD. If they have the credentials I'm not about to question their currency or competency nor should I. Any decision to divert is done in consultation with dispatch to ensure all applicable ground handling and regulatory/customs requirements are met whether it is done under Medlink's advice or not. Medlink only takes care of medical facilities and notification on your behalf, they know nothing of operational issues and that is always left up your company and YOU, who is ultimately responsible for determining if their recommended airfield is suitable or not.

If anybody decides to divert for any reason they first have to ensure that it is a suitable diversion airfield, and the way to do that is to make dispatch part of the decision making process. While the final decision always rests with the captain, the company has a say as well where their airplane ends up and that must be considered in any PIC's decision. If you decide on your own to land in Podunk, Saskatchewan without consulting or even informing dispatch and it all goes to hell on the ground then you haven't done your job properly.

If your uncle the radiologist said to me a passenger needs urgent medical care while I was flying over Winnipeg, but Medlink didn't think so, then guess who wins? Your uncle isn't diagnosing the patient, merely telling me they need urgent medical care. Any trained and licenced MD, current or not, is supremely capable of making that determination.

In any event it's hard to imagine a situation where an MD recommends immediate medical care after examining a patient and Medlink doesn't agree after hearing the symptoms over the radio. Extremely unlikely in my opinion since as you say Medlink assumes liability. They have a business to run too, and it doesn't cost them anything to land.

[Biff]

In any event it's hard to imagine a situation where an MD recommends immediate medical care after examining a patient and Medlink doesn't agree after hearing the symptoms over the radio. Extremely unlikely in my opinion since as you say Medlink assumes liability. They have a business to run too, and it doesn't cost them anything to land.

Exactly, thus the reason I would follow their advice!

[venc]

In any event it's hard to imagine a situation where an MD recommends immediate medical care after examining a patient and Medlink doesn't agree after hearing the symptoms over the radio. Extremely unlikely in my opinion since as you say Medlink assumes liability. They have a business to run too, and it doesn't cost them anything to land.

Exactly, thus the reason I would follow their advice!

These scenario's are full of what-ifs and gotcha's. I can think of two ways this scenario could play that would necessitate a different decision.
1 The doctor in back is a cardiologist and the patient is suffering from a heart attack. I will go with his recommendation to divert regardless of Medlink if I feel that the doctor isn't BS'ing me on his qualifications. If you do this, no one will hold it against you, If you don't follow his recommendation and the patient dies because of it, Medlink will be responsible but the media (read public opinion) will hang you and the company out to dry.

2 The doctor in back is a doctor of holistic medicine but considers himself a MD. I will go with Medlink on this one even though the guy in back has more medical qualifications than I and has done a physical exam.

These are 2 extreme examples and reality would likely be somewhere in between. You just have to know where you draw your own personal line (hence you are the Captain).
Medlink is a great human resource but they are human. Dispatch is a great resource but I always read over my flight plan to be sure they have done it correctly and make change as necessary. The decision is the Captain's and everything else is a valuable resource.

[Rockie]

2 The doctor in back is a doctor of holistic medicine but considers himself a MD. I will go with Medlink on this one even though the guy in back has more medical qualifications than I and has done a physical exam.

In this case you should ignore anything the guy says. No one but a nurse, MD, or paramedic with documentary proof of their credentials should be caring for a passenger at all besides the flight attendants. It would take BIG BALLS to carry on to destination when one of those three says a passenger needs urgent medical care after examining them. Would you want someone who only heard your symptoms described to him over the phone taking a chance like that with your life?

Besides, if you told Medlink that an MD was on board and recommends landing ASAP it's unimaginable they would disagree. They will simply recommend a suitable place and get the ball rolling. I only heard of one case where Medlik and an onboard MD disagreed, and that was in what medication to give the patient. They certainly agreed on the condition and necessity to land.

[shankdown]

You don't believe anyone is a medical doctor until they produce documented proof of their licence to practice medicine.

You're balancing that rather nebulous eventuality against a certified medical doctor physically examining a patient and correctly determining they require urgent medical attention.

Well I have two questions for you. Do you not consider a fully licenced medical doctor who has examined the patient an expert? And if I take the conservative approach no matter who recommends it (medlink or onboard doctor), what legal trouble could I possibly be in?

How would you know that the credentials produced aren't forged? Do you know what they look like? How do you know that the person showing you credentials is fully qualified to deal with the specific problem that the patient is claiming to be dealing with? Beyond that, how'd you know that the doctor is fully aware of how an 8000' cabin altitude can effect the passenger's case? MedLink is there for YOU.

And what legal trouble could you get in? I'm no lawyer, but lets say after diverting to Keflavik, it was determined that the doctor on board wasn't in fact a doctor, and the guy just wanted to see if he could convince the airliner to divert. His word against yours, when MedLink was telling you to continue. You could probably be in some hot water. The conservative approach is to offload any passenger with a sniffle, a cough, travelling with the use of oxygen, history of panic attacks, etc. That's probably the best and most conservative way to cover your ass. Biff is right. If the onboard credential-producing-medical-specialist-in-the-field-of-the-passenger's-ailment is really convincing, he should talk to MedLink directly and convince the guy on the other end of the SatFone. Because I personally believe you're putting yourself out there for liability if you listen to anyone other than MedLink.

I'm just guessing, but I would estimate that there are probably a hundred or so flights annually that would otherwise divert unnecessarily, in the name of being conservative and ass-covering, in the absence of MedLink. They would've safely advised each one of them against that very situation. Their service is needed, it is necessary, and they do a good job. Without them, we'd be diverting for every person complaining of chest pains. Their track record is excellent. So utilize their experience and their word, as it is the only known entity on-board your airplane when it comes to medical advice.

But that's just my opinion.

Shankdude

[Rockie]

You're reaching for some conspiracy there. I guess we should never ask if there's a doctor on board because even if he wasn't some deranged terrorist bent on diverting your plane to Saskatoon, we can't believe what he says anyway. Don't even bother asking, just call medlink.

[shankdown]

I was a passenger on AC going from YYC to LHR. During the flight, a fella, probably in his 60's, fell and hit his head. He was bleeding. There was a doctor on board who assisted in cleaning the wound, and getting him bandaged up. We continued to London.

Presumeably MedLink was contacted, who determined that the flight should continue. The doctor assisted in helping the guy out during the flight. That's why a doctor is called on from the passenger group. To assist on-scene. MedLink makes the decision on what to do as far as landing or continuing. Absent MedLink, the doctor may have said to divert, just to cover his ass against legal recourse on the off chance there was internal bleeding. Not only does MedLink take responsibility away from the Captain for making decisions like that, it also takes it away from any doctor who may be willing to help out.

The eventuality of a situation like that occuring is quite unlikely. However, it does happen, and whatever decision you, me, or anyone else makes will be second guessed, regardless of the outcome. That's just the way it goes. But I like discussions like this, as it does get us all thinking. And if nothing else, that's a good enough reason for talking about it. All you can do is make the best decision possible with the information that you have.